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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Commonest cancer in males aged 15–35 years. 95% are germ cell tumours: seminoma (~55%) or NSGCT (~45%)
- Presents as painless, hard testicular lump. Any new testicular mass in a young man = cancer until proven otherwise
- Risk factors: undescended testis (cryptorchidism — 5–10× risk even after orchidopexy), previous testicular cancer, family history
- Tumour markers: AFP (raised in NSGCT, NOT seminoma), beta-hCG (raised in both), LDH (bulk of disease)
- Treatment: radical inguinal orchidectomy (NOT trans-scrotal) + surveillance/adjuvant chemo/radio depending on type and stage. Cure rate >95%
Overview
Testicular cancer is the commonest solid organ malignancy in men aged 15–35 years. The vast majority (95%) are germ cell tumours, subdivided into seminomas (peak 30–40 years, slower growing, very radiosensitive) and non-seminomatous germ cell tumours (NSGCTs, peak 20–30 years — includes embryonal carcinoma, yolk sac tumour, choriocarcinoma, teratoma, and mixed). Non-germ cell tumours (Leydig cell, Sertoli cell, lymphoma) are rare. The strongest risk factor is cryptorchidism (undescended testis), which carries a 5–10× increased risk. Testicular cancer has an excellent prognosis with cure rates exceeding 95% overall, even in advanced disease, thanks to platinum-based chemotherapy.
Epidemiology
Approximately 2,400 new cases per year in the UK. Incidence has been rising over recent decades. Peak age 15–35 years for germ cell tumours; testicular lymphoma peaks in >60 years. Five-year survival exceeds 95% overall (>99% for stage I). Risk factors: cryptorchidism, previous testicular GCT (5% contralateral risk), family history (first-degree relative: 6–10× risk), testicular atrophy, Klinefelter syndrome, disorders of sex development.
Clinical Features
Symptoms
Painless hard lump in the testis (most common presentation)
Testicular swelling or heaviness
Dull ache in the testis or groin
Gynaecomastia (beta-hCG secretion — especially choriocarcinoma)
Back pain (retroperitoneal lymph node metastases — para-aortic nodes are primary drainage)
Dyspnoea, cough (pulmonary metastases)
Signs
Hard, non-tender testicular mass (distinct from epididymis)
Cannot get above the swelling (intratesticular — scrotal transillumination negative)
Hydrocele (reactive — associated with 5–10% of testicular tumours)
Gynaecomastia
Left supraclavicular lymphadenopathy (Virchow node — metastatic disease)
Abdominal mass (retroperitoneal lymphadenopathy)
Investigations
First-line
Scrotal ultrasoundFirst-line for any testicular mass — highly sensitive for intratesticular tumours. Shows hypoechoic solid mass (malignant) vs cystic (likely benign)
Serum tumour markers (pre-orchidectomy)AFP (raised in NSGCT — yolk sac/embryonal; NEVER raised in pure seminoma), beta-hCG (raised in seminoma and NSGCT — especially choriocarcinoma), LDH (reflects tumour bulk)
Second-line
CT chest/abdomen/pelvisStaging — assess retroperitoneal lymph nodes (primary nodal drainage for testes is PARA-AORTIC, not inguinal), lung metastases, liver
Post-orchidectomy markersRepeat AFP, beta-hCG, LDH after orchidectomy — normalisation confirms complete resection; persistent elevation suggests residual/metastatic disease
Specialist
Sperm bankingOffer BEFORE orchidectomy — fertility preservation essential in young men (treatment including chemotherapy may affect fertility)
Histopathology of orchidectomy specimenDefinitive classification (seminoma vs NSGCT), local staging (T-stage, vascular invasion)
1
Radical inguinal orchidectomy
- Performed via INGUINAL approach (NOT trans-scrotal — scrotal violation risks scrotal skin recurrence and alters lymphatic drainage)
- Spermatic cord is clamped at the deep ring before testis is delivered — prevents tumour embolisation
- Offer testicular prosthesis at time of surgery if desired
- Offer sperm banking BEFORE surgery
2
Stage I (no metastases)
- Seminoma: surveillance (preferred) or single-dose carboplatin AUC7 (adjuvant — reduces relapse from 20% to 5%)
- NSGCT: surveillance (if no vascular invasion) or 1 cycle BEP chemotherapy (if vascular invasion — reduces relapse from 50% to <5%)
- Surveillance: regular tumour markers + CT imaging (3-monthly then 6-monthly) for 5–10 years
3
Advanced/metastatic
- BEP chemotherapy (bleomycin + etoposide + cisplatin): standard regimen — 3–4 cycles depending on risk classification
- Seminoma: excellent response to both chemo and radiotherapy
- Residual masses after chemo: NSGCT — retroperitoneal lymph node dissection (RPLND) if residual mass >1 cm. Seminoma — observe if PET-negative
- Cure rate >95% for good-prognosis metastatic disease (IGCCCG classification)
Complications
- Treatment toxicity: Cisplatin: nephrotoxicity, ototoxicity, neuropathy. Bleomycin: pulmonary fibrosis (monitor DLCO). Radiotherapy: secondary malignancy risk
- Subfertility: From orchidectomy (reduced sperm count) + chemotherapy effects — sperm banking essential
- Contralateral tumour: ~5% lifetime risk — long-term surveillance with self-examination
- Psychosocial: Impact on body image, sexual function, and fertility in young men
UKMLA Exam Tips
- 1Painless hard testicular mass in a young man = testicular cancer until proven otherwise → urgent USS
- 2AFP raised = NSGCT (yolk sac, embryonal). AFP is NEVER raised in PURE seminoma — if AFP elevated, treat as NSGCT even if histology says seminoma
- 3Beta-hCG can be raised in BOTH seminoma and NSGCT (especially choriocarcinoma)
- 4Orchidectomy is via INGUINAL approach, NOT trans-scrotal (violates scrotal skin → altered lymphatic drainage → poorer prognosis)
- 5Testicular lymphatic drainage is to PARA-AORTIC nodes (not inguinal) — because testes descend from the abdomen embryologically
- 6Cryptorchidism: 5–10× increased risk of testicular cancer. Orchidopexy REDUCES risk but does NOT eliminate it completely
- 7Cure rate >95% — one of the most curable solid cancers, even when metastatic (thanks to platinum-based chemo)
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